MedicaidPrior AuthMedium impact
Prior Authorization of Complement Inhibitors – Pharmacy Services MAB 01-19-19
Pennsylvania Medicaid (DHS)·PA · Hematology, Oncology, Nephrology +2 more·Prior Authorization
Effective date
Jul 8, 2019
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) now requires prior authorization for all Complement Inhibitors including Soliris (eculizumab) and Ultomiris (ravulizumab-cwvz). These drugs treat rare conditions like paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, and generalized myasthenia gravis, with specific clinical criteria required for approval.
Action Required
By July 8, 2019: Billing team must ensure all prescriptions for Complement Inhibitors (Soliris and Ultomiris) have prior authorization before dispensing to Pennsylvania Medicaid patients. Providers must work with appropriate specialists (hematologist/oncologist, nephrologist, neurologist) and ensure patients meet FDA-approved indications and dosing guidelines. For myasthenia gravis cases, verify patients have positive anti-AChR antibodies, MGFA class II-IV, MG-ADL score ≥6, and have failed other therapies. Claims will be denied without proper prior authorization.